Provider Demographics
NPI:1407512825
Name:RIVER DENTAL BELLA VISTA PLLC
Entity Type:Organization
Organization Name:RIVER DENTAL BELLA VISTA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CREED
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-998-0996
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:
Practice Address - Street 1:3489 BELLA VISTA WAY
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-5740
Practice Address - Country:US
Practice Address - Phone:918-998-0996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty